Delirium. A Plan to Reduce Use of Restraints. David Wensel DO, FAAHPM Medical Director Midland Care

Transcription

1 Delirium A Plan to Reduce Use of Restraints David Wensel DO, FAAHPM Medical Director Midland Care

2 Objectives Define delirium Describe pathophysiology of delirium Understand most common etiologies Define how to diagnose delirium Report how to evaluate delirium Describe how to treat delirium

3 Delirium A disturbance in consciousness with reduced ability to focus, sustain, or shift attention A change in cognition that is not better accounted for by dementia A disturbance that develops over hours to days and fluctuates during coarse

4 Delirium Evidence that the disturbance is caused by consequences of general medical condition

5 Delirium Types Hyperactive Hypoactive Mixed

6 Delirium Signs Alterations in sleep-awake cycle Short and Long term memory deficits Delusions Hallucinations Emotional Lability

7 The Cost of Delirium It s presence is a predictor for: Increase Mortality Increase Morbidity Longer Hospitalization Discharge to a Nursing Facility

8 Theories of Delirium Pathophysiology Decreased Oxidative Metabolism Direct effect on neurotransmitters (<ACTH,>DA,5HT3,NE,GABA) Neurotransmitter changes with aging Increased inflammatory cytokines Stress reactions

9 Theories of Delirium Pathophysiology Changes in interneuron signal transduction Decreased cholinergic activity

10 Theories of Delirium Pathophysiology Anticholinergic Neurotransmitters are involved in: Arousal, learning and memory, REM sleep,behavior, mood, thought, perception, and orientation Serum Anticholinergic levels correlate well with severity of delirium

11 Delirium Etiology Metabolic disturbances Organ failure Medications Sepsis Brain Pathology Withdrawal from alcohol, or benzos Hematologic

12 Delirium Precipitating Factors The use of restraints Malnutrition (Alb <3.0) Addition of more than 3 medications Use of bladder catheter Iatrogenic events

13 Delirium in Cancer Patients 1/3 had cognitive dysfunction Related to Opioid dose of 400mg of morphine equivalents per day Older age Karnofsky score Lung Cancer with short time from diagnosis No Breakthrough pain medication

14 Delirium Diagnosis Often under recognized or misdiagnosed Memorial Delirium Assemessment Scale Delirium Rating Scale Confusion Assessment Method

15 Confusion Assessment Method Most researched and convenient Validated in palliative care populations Takes around 5 minutes to complete

16 Confusion Assessment Method Feature 1: Acute onset with fluctuating coarse. Feature 2: Inattention, is the patient easily distracted. Feature 3: Disorganized or incoherent thinking Feature 4: Altered LOC

17 Confusion Assessment Method Requires the presence of acute onset with fluctuating coarse, and inattention Can have either disorganized thinking or altered level of consciousness

18 Delirium It is key to differentiate dementia from delirium Delirium has a sudden onset Dementia has a slow progressive decline An acute behavior change is most likely delirium even in the setting of dementia

19 Delirium Impact Associated with prolonged hospitalization Increased Mortality: Median survival of 21 days vs. 39 days More likely to discharge to long term care facility Prolonged impact on function Increased depression and anxiety

20 Delirium Impact 30% if older hospitalized patients experience delirium Among older surgical patients the rate of delirium is between 10% and 50% Associated with older frail patients and very complex surgeries

21 Delirium Terminal Delirium is seen in at least 88% of dying patients Treatment may involve sedation 5 themes have been identified Perception of suffering, Lack of communication, Ambivalence of caregivers, A need for information, Dignity and Respect

22 Delirium Evaluation Determine Goals of Care Look for medications Consider Withdrawal of aggressive care Identify metabolic and hematologic abnormalities Look for infections Consider specialized testing if appropriate

23 Delirium Treatment Manage the causes when possible Opioid rotations Remove medications that contribute Manage dehydration Treat hypercalcemia

24 Delirium Treatment There are no FDA approved medications for the treatment of delirium Antipsychotics are commonly used in ICU s Haloperidol is the most common A Cochrane review stated there are inadequate date to make any conclusions

25 Delirium Treatment First significant study compared haloperidol, chlorpromazine, and lorazepam in 30 Aids patients with delirium No difference between haloperidol or chlorpromazine The lorazepam arm was stopped due to toxicity and worsening delirium

26 Delirium Treatment Quetiapine is the only antipsychotic that has been compared to placebo Quetiapine 25mg as starting dose with 175mg max Improvement occurred 57% faster in the quetiapine group

27 Delirium Treatment A second study with quetiapine in ICU patients showed Shorter time to resolution was found One day vs. 4.5 days with placebo

28 Delirium Treatment Atypical Antipsychotics have also been compared Haloperidol, Risperidone, Olanzapine, and Aripiprazole No statistically significant difference was seen One study with higher doses of Haloperidol did show some improvement

29 Delirium Treatment Disadvantage of atypical antipsychotics is they only come in oral or intramuscular forms Olanzapine has been used subcutaneously without reaction

30 Delirium Treatment The role of benzodiazepines is unclear They are the drug of choice for withdrawal In the study comparing them to antipsychotics they were stopped because patients became worse A Cochrane review concluded they could not be recommended for delirium

31 Delirium Treatment Treatment of hypoactive delirium is controversial American Psychiatric Association guidelines do not comment about this Most studies are confined to hyperactive delirium

32 Delirium Treatment Recommendations Haloperidol is the most cost effective option The atypical antipsychotics are no better than haloperidol The atypical antipsychotics are more expensive to use Reasonable starting doses: 0.5 to 2 mg with hourly monitoring

33 Delirium Treatment In the setting of terminal delirium sedation may be required Delirium can be very distressing to a family Midazolam and Lorazepam are the most common medications used Chlorpromazine has also been used No comparison trials have been done

34 Delirium Treatment Notice we have not talked at all about restraints Physical Restraints have clearly been shown to increase delirium They also lead to worse outcomes Bottom line is don t use them unless patient is at great risk to themselves or others

35 Delirium Treatment A better strategy is constant observation Move patient to a room closer to nurse station Use in room sitter if needed

36 Delirium Outcomes Signs of delirium may persist for up to 12 months in the setting of dementia After 2 years only 1/3 of elderly patients with delirium lived independently It is a harbinger of future problems in frail elderly 6 month mortality is 14% to 22%

37 Delirium Outcomes Protracted delirium is associated with much higher 6 and 12 month mortality Delirium in patients who also have dementia is associated with a faster rate of cognitive decline Delirium may require weeks or even months to resolve

38 Delirium Bibliography Legrand S. Delirium in palliative medicine: a review. J Pain Symptom Manage 2012;44: Lawlor PG, Fainsinger RL, Bruera ED. Occurrence, causes and outcome of delirium in advanced cancer patients: a prospective study. Arch Intern Med 2000;160:

39 Delirium Bibliography Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors in elderly hospitalized patients. J Gen Inter Med 1998;13:204